A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries

Background: Angiographic embolization (AE) is used with increasing frequency as an alternative to surgery for control of intraperitoneal and retroperitoneal bleeding. There are no prospective studies on its efficacy, safety, and indications. Patients: From April 1999 to June 2001, patients with abdominal visceral organ injuries or major pelvic fractures sent for AE were prospectively studied. Patients were transported to the angiography suite either because they were hemodynainically unstable ("emergent" angiography) or hemodynamically stable but had injuries likely to bleed ("preemptive" angiography). The efficacy of AE was derived from its ability to control bleeding radiographically and clinically; the safety of AE was determined by the complications related to transport, vascular access, catheter insertion, contrast administration, and tissue necrosis after interruption of blood supply to organs. Predictors of bleeding were identified by comparing patients who showed contrast extravasation on angiography with those who did not by univariate and multivariate analysis. Results: Of 100 consecutive patients evaluated by angiography for bleeding from major pelvic fractures (n=65) or solid visceral organ injuries (n=35), 57 were found to have active contrast extravasation and were embolized, 23 were found to have indirect signs of vascular injury or ongoing hemodynamic instability and were embolized, and 20 had no signs of bleeding and were not embolized. AE was effective and safe in 95% and 94%, respectively, of 80 patients who were embolized. Four patients had recurrent bleeding after AE and five developed AE-related complications. In three of the four patients, bleeding was controlled by repeat AE. In all five patients, the complications were managed with no further sequelae. Three independent factors were predictive of bleeding identified on angiography: age older than 55 years, absence of long-bone fractures, and emergent angiography. The presence of all three independent predictors was associated with a 95% probability of bleeding; however, the probability of bleeding was still 18% when all three independent predictors were absent. Conclusion: AE is highly effective in controlling bleeding caused by abdominal and pelvic injuries and difficult to manage by surgery. Older age, the absence of long-bone fractures, and emergent angiography increase the likelihood of finding active bleeding angiographically. However, there are no clinical characteristics to exclude reliably all patients who are not actively bleeding internally. Because of this and its reasonable safety profile, AE should be offered liberally in patients with selected injuries of the pelvis and abdominal visceral organs.